Chest X-ray Interpretation

Transcription

1 General Principles Chest X-ray Interpretation Denise Ramponi, DNP, NP-BC, FAEN 80% of all diagnosticsradiographs CXR most commonly performed 45% of all radiographs Order film based on indications Use a systematic approach Concentrate on one thing at a time Chest X-ray: Standard Views Postero-anterior (PA): On inspiration diaphragm descends to 10 th rib posteriorly If diaphragm is not at the 8 th rib = lung hypoinflation (e.g., respiratory depression) If diaphragm is past the 12 th rib = hyperinflation (e.g., asthma) PA view is better to comment on accuracy of the heart size More accurate representation of the cardiac size PA Film Lateral Film Lateral (LAT): L side placed a/the cassette (LAT) view can determine the anterior-posterior structures along the axis of the body Lateral Film Normal LAT film 1

2 AP View -Portable When the patient is unable to tolerate routine views with pts sitting or supine No participation from the patient Film is against the patient's back (supine) Chest radiograph Counting ribs 1 & 2 are above the clavicle Full inspiration: 8 ribs (10 ideal) Posterior 5-6 ribs - Anterior Sharp costophrenic angles Counting Ribs Chest radiograph Left and right heart borders well defined Both hemidiaphragms visible to midline Right -higher Heart less than 50% of diameter of the chest 2

3 Normal PA CXR Chest Landmarks A costophrenic angle B-L diaphragm C-heart D-aortic arch-superior left bend of the aorta between the ascending and descending portions E-trachea F-hilum G-carina -cartilaginous ridge within the trachea that runs anteroposteriorly between the two primary bronchi at the site of the tracheal bifurcation at the lower end of the trachea (usually at the level of the 4 th or 5th thoracic vertebrae) H-stomach bubble J-ascending aorta Rotation Centered? Rotation pulmonar/cxr/cxr_f.htm 3

4 Normal CXR Lateral Films Normal LAT Film ZCicpA9mZcRmbr81UgK2Wpg-YyNY7/normallung.jpg Dextrocardia Lobes of the Lungs Dextrocardia situs inversus: heart is a mirror image of normal placement Dextrocardia situs totalis - all visceral organs are mirrored Incidence -1 in 12,000 people Surface Anatomy w.meddean.luc.edu/lumen/mede d/medicine/pu icine/pulmonar/cxr/cxrl5.htm Rothenberg, M. A. (1998). Understanding X-rays: A plain english approach, PESI. 4

5 Right Lung RUL/RML Right Lung RLL/Diaphragm Lateral RUL & RML Left lung LUL/L Lingula Left Lung -LLL Lateral -LL 5

6 Clues to consolidation Ill Defined Right heart border Left heart border Right hemidiaphragm Left hemidiaphragm Consolidation suspected Middle lobe Left upper lobe (lingula) Right lower lobe Left lower lobe Penetration Under & Over Exposed Spine Sign/Breast Shadows Silhouette Sign Loss of a cardiac border may indicate a lung abnormality adjacent to that anatomical structure Obscuration of right border of heart (arrows) due to density of another tissue 6

7 Silouette Sign Snowball Sign Is nodule arising from lung or surrounding structure? LUL: Mass vs. Infiltrate 53 yr old female Fever & Cough 64 yr old with SOB & cough 7

8 Rules= RIP R Rotation clavicles and vertebrae form a cross I Inspiration minimum of 8 ribs visible P Penetration interspaces visible; thoracic vertebral bodies not well defined Symmetry right hemidiaphragmhigher & aortic knob Lung markings all the way out Cardio-thoracic ratio Extracardiac causes for CTR>50% Portable AP films Obesity Pregnancy Ascites Straight back syndrome Pectus excavatum 8

9 Cardiomegaly & AP film Pericardial Effusion If the heart touches the lateral chest wall, it s enlarged Poor vs. good inspiration Both hemidiaphragms seen Area behind heart approx as black as area behind sternum Lower vertebral bodies darker compared with upper Chest Radiograph Steeple sign of croup (subglottic narrowing) 9

10 Pleural Effusion Need at least ml to be able to view Right Lateral Decubitus film Pulmonary Vasculature Normal Pulmonary Artery and Hilar Markings 10

11 Kerley B Kerley B lines Magnified CXR Cardiomyopathy & interstitial pulmonary edema Short 1-2 cm white lines at lung periphery horizontal to pleural surface Distended interlobular septa -secondary to interstitial edema. emedicine.medscape.com/article/ media Prominent interstitial markings Kerley lines Congestive Heart Failure Alveolar edema=air sacs (i.e., alveoli) Interstitial edema = alveoli + supporting structures Bat Wing edema Bat wing edema = central, alveolar edema < 10% of cases of pulmonary edema occurs with rapidly developing severe cardiac failure acute mitral insufficiency renal failure Clinical and Radiologic Features of Pulmonary Edema apasso&sortspec=date&submit=submit 11

12 CHF Widened Mediastinum Aortic Dissection Rib fractures Chest radiograph obtained solely to exclude complication such as pneumothorax Oblique views of the ribs are not necessary; clinical management is rarely altered by seeing rib fx. Rib Fractures Unrestrained driver involved in MVC 12

13 Shortness of Breath 3 yr old with fever & barky cough MVC c/o right chest pain Expiration Views Air trapping conditions: Pneumothorax Partial bronchial obstruction Foreign body aspiration if you hear a unilateral wheeze that does not clear with coughing! Pneumothorax Consider expiratory film if small 13

14 Pneumothorax Hemothorax Key Points AP radiograph may magnify the heart, poor inspiration Small pneumo expiration view Chest radiograph done with rib fractures used to exclude complication Both heart borders & both hemidiaphragms normally clearly visible Coin vs. Button Batteries 14

15 Asthma Asthma Hyperinflation Mucus plugging can lead to atelectasis Interstitial inflammation Hyperinflation with flat diaphragm down to the 11 th rib Prominent interstitial markings (scarring) from inflammation COPD COPD Hyperinflation (loss of interstitial tissue/darker-more air) low set diaphragm/ 12 th rib increased AP diameter vertical heart increased retrosternal air. blunted costophrentic angles COPD 15

16 Severe COPD with pneumomediastinum and SQ emphysema MVC high velocity with SOB Trauma pt, fall from 14 ft, c/o SOB 16

17 15 month old suddenly red in face and SOB Fever, cough, SOB History CA Lung with SOB 28 yr old female with cough 17

18 48 yr old patient wheezing 4 yr old choking episode 2 year old choking episode Fever, productive cough, SOB 18

19 Pt c/o cough and wheezing for 1 month after seizure episode Fever, cough, noisy respirations 4 yr old with choking episode Fever, wheezing Thrown from motorcycle, c/o CP, SOB 7 yr old found with mother s purse 19

20 13 yr playing with blowgun 5 Key Points Good Inspiration minimum 8 ribs Ill-defined heart borders & diaphragms determines location of infiltrates Heart should be less than 50% chest Lung markings all the way to periphery Coin/button batteries orientation, flat in esophagus 20